Search

Category: Quality/Systems Improvement | QI/Research Title: Getting Mammograms Shouldn’t Be So Bumpy- Improving Mammogram Workflow in VA Community CarePrimary Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident) Co-Authors and Specialty Program Affiliations: Jack Temple, MD (Internal Medicine), Susan Macdonald, RN (VA Community Care), Shayne Ovalles, RN (VA Community Care)  Background The interplay between Community Care (CC) and VA-based care has long been important for continuity of patient care, though transitioning care between the two is often fraught with problems. Mammograms ordered at VA San Diego (VASD) are often deferred to community care; while this process should be smooth and seamless, the process is instead convoluted and ripe for errors. The lack of standardization, disconnect between the interface between VASD and CC, and splintered tracking systems has led to delays in care, delays in results, and at worst, patient harm and delays in diagnosis. VA mammograms completed in the community have inconsistent rates of completion, with errors ranging from unscheduled appointments, delayed provider notification, and loss to follow up leading to late diagnoses of breast cancer. To reduce patient harm and increase fluidity of VA mammograms in the community, we applied extensive QI methodology towards overhauling the VA Community Care Mammogram workflow. Methods We evaluated the process of CC mammograms at VA San Diego. An A3 was used to process map the VA CC Mammogram process, beginning with VA provider entering a mammogram order to the community and ending with mammogram result release to the patient. A virtual Gemba walk was performed, during which the author evaluated how the CC team processed consults and results. Using Lean Six Sigma process improvement strategies, we identified several problematic areas within the CC Mammogram workflow that are prone to errors and can lead to patient safety issues. Weekly meetings and interviews were set

Title: I’ll make a “Patient” out of you: An Update to “Physicians as ‘Patients’”- Design, Implementation, and Challenges of Novel Immersive Simulated Patient Experiences to Foster Physician Empathy and Compassion Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident) Co-Authors and Specialty Program Affiliations:  Khanh Hoang Nicholas Le, MD (Internal Medicine, PGY-1), Preetham Suresh, MD (Anesthesia, faculty), Ricardo Wood (UCSD Simulation Center), Sean Kenmore, MD (Internal Medicine, faculty)  Issues Addressed/ Background The importance of fostering physician empathy and compassion has become increasingly recognized as a critical aspect of physician training, with the ACGME and AAMC both acknowledging empathy as a key component of professionalism, with recommendations to incorporate empathy education into core medical education goals. The challenge remains how best to teach physician empathy and compassion in medical education, and to create long term effective educational interventions. Empathy curriculum in graduate medical education remains limited, as there are few standardized methodologies for teaching empathy.  Herein lies an opportunity for growth and development of novel and new methodologies to deliver patient-centered and empathy/compassion education to physicians in training. We hypothesize that lack of appreciation or understanding of the patient experience is much to blame in the deficits in teaching physician empathy and compassion. To address this void, we propose a set of novel immersive simulation exercises to place resident physicians in the role of a patient with space for guided reflection. We propose that a standardized longitudinal curriculum based on high-fidelity immersive simulation exercises throughout medical training will improve physician empathy and compassion, and the delivery of this form of education can be effective, easily disseminated, cost effective, and enjoyable to the learner, ultimately l

TITLE: Physicians as “Patients”- Use of immersive simulated patient experiences to foster physician empathy and compassion AUTHORS: Aaron M. Lee, DO; Sean Kenmore, MD; Supraja Thota, MD; Constance Chance, MD; Anand Jagannath, MDINSTITUTION: Internal Medicine, University of California-San Diego Medical Center   BACKGROUND The importance of fostering physician empathy has become increasingly recognized as a critical aspect of physician training; among many things, increased physician empathy has been shown to lead to improved clinical outcomes, higher patient satisfaction, and decreased physician burnout. Despite this, there remains a paucity of interventions to effectively promote compassion and empathy in medical education. To address this void, we propose a set of novel immersive role-reversal simulation exercises which place resident physicians into patient roles to simulate the inpatient experience. We propose that increased appreciation of the patient experience through simulation can lead to improved physician empathy and compassion and thereby improved delivery of patient-centered care.   PILOT INTERVENTION While the ultimate goal is to develop a formal curriculum involving numerous simulation didactics, we developed a pilot program to study the initial feasibility and effectiveness of this intervention.Aim: Use of a 1-hour noon conference to expose end-of-year interns to numerous aspects of the patient experience to increase appreciate of the inpatient experienceMethods: Several different stations were developed that each highlighted a single aspect of the patient experience. At each station, a prompt provided a simulated patient context/perspective associated with a physical item. These stations included a hospital bed, patient foods, glucometers, bedpans, common patient foods, urinals, nasal cannulas/facemasks, incentive spirometer, oral secretion device, foley and urine leg bag. Participants were given patient gowns, telemetry leads, pulse oximet

The computational advances of the past several decades have allowed theoretical astrophysics to proceed at a dramatic pace. Numerical simulations can now simulate the formation of individual molecules all the way up to the evolution of the entire universe. Observational astrophysics is producing data at a prodigious rate, and sophisticated analysis techniques of large data sets continue to be developed. It is now possible for terabytes of data to be effectively turned into stunning astrophysical results. This is especially true for the field of star and planet formation. Theorists are now simulating the formation of individual planets and stars, and observing facilities are finally capturing snapshots of these processes within the Milky Way galaxy and other galaxies. While a coherent theory remains incomplete, great strides have been made toward this goal.This dissertation discusses several projects that develop models of star and planet forma- tion. This work spans large spatial and temporal scales: from the AU-scale of protoplanetary disks all the way up to the parsec-scale of star-forming clouds, and taking place in both contemporary environments like the Milky Way galaxy and primordial environments at redshifts of z~20.Particularly, I show that planet formation need not proceed in incremental stages, where planets grow from millimeter-sized dust grains all the way up to planets, but instead can proceed directly from small dust grains to large kilometer-sized boulders. The requirements for this model to operate effectively are supported by observations. Additionally, I draw suspicion toward one model for how you form high mass stars (stars with masses exceeding ∼ 8 Msun), which postulates that high-mass stars are built up from the gradual accretion of mass from the cloud onto low-mass stars. I show that magnetic fields in star forming clouds thwart this transfer of mass, and instead it is likely that high mass stars are created from the gravitational collapse of

The purpose of this project was to create Epic EHR user guides for each of the various roles at our UCSD Student-Run Free Clinic Project. Because this EHR system is integrated with the rest of the UCSD Health System, and because we function as the primary care providers for our patients, we need to ensure the accuracy of our patient care documentation. But at the same time, we must ensure efficient use of time at our free clinic sites, in order to respect the time of our volunteers. These user guides will therefore allow new users to become quickly acquainted with our customized free clinic EHR context, and will allow them to successfully navigate the multi-variate EHR environment. A multi-step process was undertaken to identify current EHR users at our free clinics, to outline their roles and responsibilities regarding their current interactions with the EHR system, and to create detailed yet succinct illustrated guides to ensure continuity of EHR usage across different users, different clinic sites, and across time since we transition student leadership roles every year. We then solicited user-specific feedback from their respective guides and incorporated that feedback into final versions, which are now posted in a centrally accessible location for all users to reference. We hope to ensure that future generations of free clinic providers and staff will be able to successfully utilize our EHR system, thus ensuring accuracy and efficiency in our patient care documentation.

Coronary artery aneurysms remain a life-threatening complication of Kawasaki disease (KD), the most common form of pediatric acquired heart disease in developed countries (1). Potentially life-threatening coronary artery aneurysms (CAA) develop in 25% of untreated children and 5% of children treated with high dose intravenous immunoglobulin during the acute phase of the self-limited vasculitis (2). Non-coronary artery aneurysms (NCAA) in extra-parenchymal, muscular arteries occur in a minority of patients with KD (2%) who also develop coronary artery aneurysms (CAA) (3, 4), yet little is understood in their formation and remodeling. We postulated that activation of the transforming growth factor TGF beta pathway may influence formation and remodeling of aneurysms in iliac and axillary arteries in KD, the two most common sites for NCAA. We studied the resected axillary artery from one adult and endarterectomy tissue from the iliac artery from a second adult, both with a history of CAA and NCAA following KD in infancy. Histology revealed destruction of the internal elastic lamina with myofibroblastic luminal proliferation, organized thrombus, and recanalization of the axillary artery aneurysm and organized thrombus with dense calcification in the endarterectomy specimen. Immunohistochemistry for molecules in the TGF[beta] signaling pathway revealed increased expression of TGF[beta]2, TGF[beta] receptor, and phosphorylated SMAD3. These findings suggest on-going tissue remodeling of the aneurysms decades after the acute injury and demonstrate the importance of the TGF[beta] signaling pathway in this process